PA-ELR Laboratory Registration Form

Directions for completing form:

ONLY Hospital and Reference Laboratories which result tests IN-HOUSE for PADOH Reportable Conditions are eligible for this service.
Private practice entities are NOT eligible and will not be contacted about ELR services.
Provide all information and answers to the questions. Note: incomplete forms will not be processed.
Questions please contact the Help Desk at (717) 783-9171 or send an email to ra-dhnedss@pa.gov.

Please note that completing this registration form is the first step of the process to gain access to PA-NEDSS and PA-ELR. You will not be automatically granted access to PA-NEDSS and/or PA-ELR by completing this form. Onboarding for Hospital and Reference Laboratories is at the sole discretion of PADOH. Entities other than Hospitals and Reference Laboratories (i.e. Private Practice Physicians) are not eligible and will not be contacted for ELR services.

If there are questions about Meaningful Use compliance, contact CMS directly.

SECTION 1: ORGANIZATIONAL INFORMATION

ORGANIZATION's MAILING ADDRESS

Health System Name:
Organization Name:
Address Line 1:
Address Line 2:
City :	State: Zip:
Phone:	ex. (999) 999-9999 x999
County:
CLIA ID:
NPI:

Federal Employer Identification Number: ex. 99-9999999

LABORATORY CONTACT INFORMATION

Lab Contact Name :
Lab Contact Title :
Lab Contact Phone:	ex. (999) 999-9999 x999
Lab Contact Email:

ORGANIZATION'S INFORMATION TECHNOLOGY CONTACT INFORMATION

LIT Contact Name :
IT Contact Title :
IT Contact Phone:	ex. (999) 999-9999 x999
IT Contact Email:

Which exportable data format(s) can your System generate? (check all that apply)
HL7 v2.3
HL7 v2.3.1
HL7 v2.5.1
Comma Delimited
Other (Please Specify)

Which Standard Code Sets does your system utilize? (check all that apply)
LOINC
SNOMED
HL7
ISO+ (ISO Customary Units)
UCUM (Unified Code for Units of Measure)
Other (Please Specify)

Please indicate in the table below the type of test(s) and estimated volume(s) your organization will report through PA-ELR (at least one is required.)

Type of Tests	Estimated Number of Test Results
Infectious Diseases		Per
STD		Per
Lead		Per
HIV		Per
TB		Per
Other		Per
If "Other" please specify

Is your organization onboarding to meet Meaningful Use requirements?
Yes No

If you answered yes you must complete Section 2 Meaningful Use, otherwise proceed to Section 3.

Section 2: Meaningful Use

If your facility is onboarding for the purposes of Meaningful Use this section must be completed.
A separate registration form must be completed for each facility that will attest for Meaningful Use compliance.
The expectation of the Pennsylvania Department of Health (DOH) is regardless of the Meaningful Use stage that an organization is attesting, once the onboarding process starts the organization commits to working towards ongoing submission. If an organization begins the process and does not follow through to ongoing submission, that organization will be placed back in the onboarding queue and resuming the onboarding process will be prioritized by the DOH.

Meaningful Use registrants will automatically be placed in the PA-ELR On-Boarding Queue. Meaningful Use registrants will be contacted at PADOH's discretion to begin the ELR onboarding process. Meaningful Use registrants have 30 days to comply with the PADOH request to proceed or the registrant will be placed back in the PA-ELR On-Boarding Queue. Failing to respond to PADOH's request to proceed may impact the facility's Meaningful Use compliance status.

Is your organization currently or planning to submit ELR messages through an HIE?
Yes No
If Yes, Regional HIE Name:

Is your organization currently submitting messages through ELR in a non-Meaningful Use compliant format?
Yes No

Which Meaningful Use Stage is this your organization onboarding for?

Section 3: Technical Requirements

What certified technology will generate the MU compliant message?
Vendor:

Version:

Which operating system does the computer (desktop PC or server) that will be sending ELR data to the PA Department of Health run under?
Windows (Please Specify)

Unix/Linux (Please Specify)

Other (Please Specify)

Which version of Microsoft .NET Framework is installed?

Which web browser is installed?

Is a Proxy Server in use?
Yes No

Is a Static IP assigned to the PC/Server?
(If "Yes", the Static IP address will need to be added to your firewall exceptions list.)
Yes No

Are Firewall rules used to gain access to the internet?
Yes No